CMS Proposes Screening Coverage for Sexually Transmitted Infections

The Centers for Medicare & Medicaid Services (CMS) recently announced a proposal to cover screenings for a variety of sexually transmitted infections (STIs), as well as high intensity behavioral counseling (HIBC) to prevent STIs.

Specifically, CMS proposes the following coverage for laboratory tests approved by the U.S. Food and Drug Administration (FDA), when ordered by the primary care provider and performed by an eligible Medicare provider:

  • Screening for chlamydia and gonorrhea for:
    • Pregnant women who are 24 years old or younger when the diagnosis of pregnancy is known, with repeat screening during the third trimester if high-risk sexual behavior has occurred since the initial screening test
    • Pregnant women who are at increased risk for STIs when the diagnosis of pregnancy is known, with repeat screening during the third trimester if high-risk sexual behavior has occurred since the initial screening test
    • Annually for women at increased risk for STIs
  • Screening for syphilis for:
    • Pregnant women when the diagnosis of pregnancy is known, with repeat screening during the third trimester and at delivery if high-risk sexual behavior has occurred since the previous screening test
    • Annually for men and women at increased risk for STIs
  • Screening for hepatitis B for:
    • Pregnant women at the first prenatal visit when the diagnosis of pregnancy is known, rescreening at time of delivery for those with new or continuing risk factors

CMS is also proposing to cover up to two, 20-to-30 minute, face-to-face counseling sessions annually for Medicare beneficiaries for HIBC to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs, when referred by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting.

HIBC is defined as a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing flexibility for appropriate patient-focused elements:

  • Education
  • Skills training
  • Guidance on how to change sexual behavior

High/increased risk individual sexual behaviors include:

  • Multiple sex partners
  • Using barrier protection inconsistently
  • Having sex under the influence of alcohol or drugs
  • Having sex in exchange for money or drugs
  • Age (24 years of age or younger and sexually active for women for chlamydia and gonorrhea)
  • Having an STI within the past year
  • IV drug use (for hepatitis B only)
  • Men having sex with men (MSM) and engaged in high-risk sexual behavior, without regard to age

In addition to individual risk factors, community social factors (such as high prevalence of STIs in the community populations) should be considered in determining high or increased risk for chlamydia, gonorrhea, and syphilis, and for recommending HIBC.

In defending its proposal, CMS noted that despite advances in both prevention and treatment, STIs remain an important cause of morbidity, and that rates of STIs in the United States exceed those in all other industrialized countries. Direct medical costs associated with STIs in the states are estimated at $15 billion annually. CMS is requesting public comment prior to making a final determination.

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